Modulate the prevention stategy according to the level of frailty - PowerPoint PPT Presentation

Modulate the prevention stategy according to the level of frailty Prof Leocadio Rodríguez Mañas Hospital Universitario de Getafe

CONFLICT OF INTEREST DISCLOSURE I have no potential conflict of interest to report

Is it possible to assess “ the level of frailty ”? Is there different clinical phenotypes of frailty? Is there any evidence-based strategy to prevent frailty? Is it the prevention strategy the same in different settings?

Frailty as a dynamic functional state CARE FOCUSED ON Preventing Preventing Preventing Preventing Managing frailty Disability Disabilty Dependency Dependency Treating Treating Treating Frailty Functional Disability Decline Potential reversibility of functional decline Robust Frail Functional Disability Dependency Limitation Definition Interventions to What What What What What improve quality How How How How How and outcomes - Where Where Where Where Where and prevent or delay further ? ? ? ? ? functional decline

Frailty conceptual models B) Frailty phenotype A) Deficit accumulation Fried et al. J Gerontol Med Sci. 2001;56A:M146-M156 Rockwood K. J Am Geriat Soc. 2006;54:975-979 Rodriguez-Mañas L & Walston JD Rev Esp Geriatr Gerontol 2017

The functional continuum Isolated Physiological Multiple MULTYSYSTEMIC Non-reversible Vulnerability conditions IMPAIRMENT DISABILITY-DEPENDENCY ROBUSTNESS DEATH SEVERE DEPENDENCY FUNCTIONAL RESERVE LOW CURRENT TOOLS: DICHOTOMIC (FRAIL vs NON-FRAIL)

Frailty Trait Score (FTS) vs Frailty Phenotype Frailty Trait Score (0-100) Frailty Phenotype (Robust/Pre-frail/Frail) Domain Item Criteria Domain/ Item Criteria (Score) (Score) Energetic BMI BMI Energetic Weigth loss >4.5 Kg/12m balance/ Weigth loss >4.5 Kg/12m balance/ Nutrition Abd. Obesity Waist circum Nutrition (0-32) Serum Alb. Lowest Quin. (1) (mg/dl) Weakness Grip strength Lowest Quin. Weakness Grip strength Lowest Quin. (0-16) Knee extension Lowest Quin. (1) Endurance Chair test (times Lowest Quin. Endurance Exhaustion CES-D (2 qst) (0-10) stand. up/30 sc) (1) Slowness Gait speed Lowest Quin. Slowness Gait speed Lowest Quin. (0-8) (1) Low activity PASE Lowest Quin. Low activity Kcals/week Lowest Quin. (0-8) (1) Nervous Fluency (animals in Lowest Quin. System 60 s) (0-16) Balance SPPB criteria Vascular Brachial/Ankle Index Fowkes criteria system (0-10)

CHARACTERIZATION OF FRAILTY STATUS BY FRAILTY TRAIT SCORE (FTS) Variable [0-20] (20-30] (30-40] (40-50] (50-60] (60-70] (70-100] N 150 262 401 418 287 201 106 Age 70 (68, 73) 72 (69, 75) 73 (70, 77) 75 (71, 78) 77 (74, 81) 79 (75, 83) 81 (77, 85) Men (%) 64.00 55.34 48.38 41.63 33.80 35.32 21.70 0.28 0.29 0.31 0.34 0.40 0.46 0.54 FI (Rockwood) (0.25, 0.31) (0.26, 0.33) (0.27, 0.35) (0.30, 0.40) (0.34, 0.47) (0.39, 0.55) (0.45, 0.60) Frailty status (% across categories) Robust 16.32 25.28 30.18 21.47 6.01 0.74 0.00 Prefrail 2.00 6.67 18.93 27.87 25.33 15.33 3.87 Frail 0.00 0.00 2.41 7.83 18.67 36.75 34.34 Carnicero JA, Caballero MA, Rodríguez-Mañas L, 2017

CHARACTERIZATION OF INCIDENT ADVERSE OUTCOMES BY FTS SCORE pv test for Variable [0-20] (20-30] (30-40] (40-50] (50-60] (60-70] (70-100] trend N 150 262 401 418 287 201 106 Age 70 72 73 75 77 79 81 Men (%) 64.00 55.34 48.38 41.63 33.80 35.32 2170 Frailty status (% across categories) Robust 16.32 25.28 30.18 21.47 6.01 0.74 0.00 Prefrail 2.00 6.67 18.93 27.87 25.33 15.33 3.87 Frail 0.00 0.00 2.41 7.83 18.67 36.75 34.34 Outcomes Death (%) 4.67 6.11 7.98 12.92 24.04 40.80 53.77 <0.001 3.1E-42 Hospi (%) 8.67 15.65 18.95 24.88 28.92 33.33 28.30 <0.001 3.8E-11 inc. Disability 1.16 12.56 20.86 32.83 44.56 54.55 57.45 <0.001 6.9E-29 (%) falls (%) 15.50 17.86 20.17 22.32 28.21 29.09 27.66 <0.001 2.6E-4 fear to falling (%) 27.91 37.39 40.52 53.61 51.05 50.91 61.36 <0.001 9.6E-9 Carnicero JA, Caballero MA, Rodríguez-Mañas L, 2017

70% Robust people Mi. Mo./Sev. 70% Prefrail people 70% Frail people Carnicero JA, Caballero MA, Rodríguez-Mañas L Mi. Mo. Sev. 2017

Table 3: Combining both frailty and sarcopenia Frailty N=1611 Robust Pre-Frail Frail 8 % EWGSOP Sarcopenic 352 (21.8%) 182 (17.3) 141 (29.3) 29(40.3) 3.4 % Non-sarcopenic 867 (82.7) 340 (27.2) 43 (59.7) 1250 (78.2%) 7.6 % FNIH Sarcopenic 348 (33.3) 303 (62.9) 54 (76.1) 705 (43.7%) Davies B, F García-Garcia 1.9 % Non-sarcopenic FJ, Ara I, Walter S, 698 (66.7) 179 (37.1) 17 (23.9) 894 (56.3%) Rodriguez-Mañas L 22 % JAMDA, 2017 Quintiles Sarcopenic 31 (3.0) 84 (17.5) 29 (40.8) 134 (8.3%) 2.9 % Non-sarcopenic Table 4. Sensitivity and specificity Frailty 1014 (97.0) 397 (82.5) 42 (59.2) 1453 (91.7%) N=1611 Sensitivity Specificity PPV NPV Frailty and sarcopenia are EWGSOP 0.60 (0.47, 0.21 (0.19, 0.03 (0.02, 0.92 (0.88, 0.71) 0.23) 0.05) 0.94) related but different entities FNIH 0.24 (0.14, 0.43 (0.40, 0.02 (0.01, 0.92 (0.90, 0.35) 0.45) 0.03) 0.94) Sarcopenia is not useful to screen frailty (low PPV) but to Quintiles 0.60 (0.47, 0.08 (0.06, 0.03 (0.02, 0.80 (0.73, 0.71) 0.09) 0.04) 0.86) rule it out (very high NPV)

Raising misclassification with changing risks Alonso Bouzón C, Carnicero JA, Turín JG, García-García FJ, Esteban A, Rodríguez-Mañas L. JAMDA, 2017

Time to event Alonso Bouzón C, Carnicero JA, Turín JG, García-García FJ, Esteban A, Rodríguez-Mañas L. JAMDA, 2017

Frailty classification by tool and setting Fried FRAIL Grng Rockw ISAR Bald G8 VES 13 Total Setting Tilbg (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Emergency 50,51 40,71 68,14 74,34 47,46 78,76 -- -- -- 60,00 Room Cardiology 61,39 41,36 65,55 62,32 42,47 -- -- -- -- 54,61 Elective 24,67 15,48 30,32 30,72 5,16 -- -- -- -- 21,27 Surgery Urgent 53,33 41,54 37,50 50,77 18,46 -- -- -- -- 40,32 Surgery Oncology 47,92 30,00 36,00 40,00 6,00 -- 14,28 81,63 34,69 36,31 Agregate 47,43 33,67 51,27 53,23 28,34 -- -- -- -- 42,78

70% Robust people 90% Prefrail people

OCTOBER, 2015

D E A T H Functional Capacity Successful Disability Usual Death Accelerated The Energetic Pathway to Mobility Loss: An Emerging New Framework for Longitudinal Studies on Aging Jennifer A. Schrack, J Am Geriatr Soc . 2010 October ; 58(Suppl 2): S329 – S336.

Observational studies: Nutrition: Macronutrients and adherence to Mediterranean Diet and Mediterranean Drinking pattern Physical activity: Avoiding sedentariness, Mod-Vigor physical exercise Ideal CV risk: Diet rich in fruit and vegetables, moderate exercise, non obesity, non diabetes Del Pozo-Cruz y cols., PLoS One 2017 Sandoval-Insausti et al., J Gerontol 2016 McClintock et al., PNAS 2016 Garcia-Esquinas et al., JAMDA, 2015 Ortolá R et al., J Gerontol 2016 Graciani et al., Circ Cardiovasc Qual Outcomes., 2016

Interventional studies: Nutrition: ?????????? Outcomes: SPPB Physical activity: LIFE study (pre-frail and frail) Non-robust Ideal CV risk: MID-FRAIL study (pre-frail an frail) Sample size (Size effect) Time of follow-up Clinical phenotypes Settings

IS IT POSSIBLE TO DESIGN SUCH A FLOWCHART FOR FRAILTY AT RISK NO YES SCREENING NO YES DIAGNOSIS NO YES PROGNOSIS TREATMENT

Is it necessary to modulate the prevention strategy according to the level of frailty? Yes INTUITIVE NOT EVIDENCE-BASED How should it be modulated Clinical Phenotypes By severity GREAT OPPORTUNITIES FOR RESEARCH By comorbidity By setting With which approaches OBSERVATIONAL STUDIES Improving diet RCT S Physical exercise Managing cardiovascular risk Others

THANK YOU e.mail: leocadio.rodriguez@salud.madrid.org